Endoscopy Brief: Transurethal cystoscopy and diode laser incision to correct an ectopic ureter


Endoscopy Brief: Transurethal cystoscopy and diode laser incision to correct an ectopic ureter

Sep 01, 2006

An 8-week-old 16.5-lb (7.5-kg) female Labrador retriever puppy was presented for evaluation of urinary incontinence. The puppy's incontinence had been present since the owner obtained the puppy at 4 weeks of age.

Figure 1. The opening of the right ectopic ureter in the distal urethra.
The physical examination revealed that the perineal area was constantly wet, and anything that the puppy was placed on became saturated with urine within minutes. The results of a complete blood count, a serum chemistry profile, thoracic and abdominal radiography, and electrocardiography were normal. A urinalysis revealed pyuria (25 to 30 WBC/HPF), bacteriuria (2+ rods), and a specific gravity of 1.032. Urine culture results were positive for Klebsiella pneumoniae and Proteus mirabilis. An ectopic ureter was tentatively diagnosed, and transurethral cystoscopy was planned.

Figure 2. The opening of the normal left ureter in the bladder.
The patient was premedicated with acepromazine and glycopyrrolate given subcutaneously. Anesthesia was induced with intravenous propofol and was maintained with inhalant sevoflurane. Lactated Ringer's solution was administered intravenously during the procedure. The puppy was placed in left lateral recumbency, and diagnostic transurethral cystoscopy was performed by using a 2.7-mm-diameter rigid telescope (model 64018 BSA—Karl Storz Veterinary Endoscopy) and saline irrigation.

Figure 3. The right ectopic ureter is visible as the ridge (arrow) in the urethra proximal to the opening of the ureter as shown in Figure 1.
The patient was then placed in ventral recumbency, and cystoscopy revealed an ectopic right ureter opening into the distal urethra within one centimeter of the urethral orifice (Figure 1) and a normal left ureteral stoma opening into the bladder (Figure 2). The urethra was dilated, and the ectopic ureter could be seen as a ridge coursing the full length of the urethra (Figure 3). The bladder appeared normal, and clear urine flowed from the normal left ureter into the bladder and from the ectopic right ureteral stoma into the distal urethra.

Figure 4. Cutting the free wall of the ectopic ureter, or septum between the ureter (A = ureteral lumen) and the urethral lumen (B), with the diode laser (C = laser fiber).
During this procedure, a diode laser was used with cystoscopic guidance to transect the free wall of the ectopic ureter (Figure 4) from its ectopic stoma in the distal urethra for the full length (about 3 to 4 cm) of the urethra (Figure 5) and to create a new stoma at the level of the contralateral normal stoma within the bladder. A flexible 1,000-µm quartz diode laser fiber was passed through the biopsy channel of the endoscope operating sheath (model 67065C—Karl Storz Veterinary Endoscopy) and connected to a 980-nm-wavelength 50-W diode laser (AccuVet 50D—AccuVet Laser Surgery) set on continuous mode with a power setting of 20 W. The tip of the laser fiber was inserted into the ectopic ureter lumen, and the laser was activated to cut the free wall of tissue separating the ureteral lumen from the urethral lumen cranially into the bladder to the level of the normal contralateral ureteral stoma (Figure 6). The right ureter thus opened in the bladder in a normal location, and there was no longer a ureteral lumen in the urethra. Urine flowed from the ureter into the bladder normally. The entire procedure was performed using transurethral cystoscopy; open surgery was not required.